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Slipped Capital Femoral Epiphysis
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Contents
Other Names
- SCFE
Background
- This page refers to Slipped Capital Femoral Epiphysis (SCFE), a pathologic process seen in skeletally immature individuals where the epiphysis is noted to slip off the metaphysis
- This can also be referred to as Salter Harris 1 Fracture
History
- Originally described by Ambrose Pare in 1572 [1]
Epidemiology
- Manifests at the average ages of 13.5 (boys) and 12 (girls)
- Boys constitute 60% of cases
- Typically occurs in overweight and obese adolescents
- Half of adolescents with SCFE at are the 95th percentile of weight for their age [2]
- Various racial frequencies
- 1.0 for Caucasians
- 2.5 for Hispanics
- 3.9 for African Americans
- 5.6 for Polynesians
- Incidence is 0.33 /100,000 to 24.58/ 100,000 children aged 8-15 years old [3]
Pathophysiology
General
- The capital femoral epiphysis becomes displaced from the metaphysis
- This occurs through the epiphyseal plate
- The slip can be varus (medial and posterior epiphyseal displacement) or valgus (lateral and superior displacement)
- 18-50% of children experience bilateral SCFE
- 50-60% of children who experience bilateral SCFE are afflicted simultaneously on each side
- The children who present with unilateral involvement experience a contralateral SCFE within 18 months [3]
- Due to a combination of both mechanical and metabolic factors
- Mechanical factors
- The physis experiences an abnormally high load due to obesity
- Femoral retroversion and increased physeal obliquity also predisposes the physis to slippage
- Metabolic Factors
- Physis itself is abnormally weak, potentially due to
- Endocrine disorders
- Dysregulation of chondrocytes in hypertrophic layer of physis[4]
Associated Conditions
- Endocrine Disorders
- Hypothyroidism
- Human Growth Hormone supplementation
- Hypogonadism
- Panhypopituitarism[5]
- Renal Failure Osteodystrophy
- Radiation Therapy [2]
Risk Factors
- Adolescent Obesity [2]
Differential Diagnosis
- Fractures And Dislocations
- Arthropathies
- Muscle and Tendon Injuries
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
Clinical Features
- History
- Patients complain of pain poorly localized to the groin, thigh, or knee
- Patients may limp
- Physical Exam
- Decreased Range of motion of the hip, especially internal rotation
- Obligatory external rotation when hip is flexed to 90 degrees
- Patients with stable SCFE are able to bear weight on affected hip
- Patients with unstable SCFE are unable to bear weight on affected hip [6].
Evaluation
Radiographs
- Need to obtain an anteroposterior view and frog-leg lateral view of the pelvis
- Findings seen on anteroposterior radiograph
- Steel Sign: a double density that is localized to the metaphysis, due to the epiphysis slipping and becoming superimposed on the metaphysis
- Klein’s line: A line drawn from the superior aspect of the femoral neck should intersect with the epiphysis
- In a patient with SCFE, the epiphysis is below this line
- A widended growth plate compared to the contralateral side
- Shortened epiphyseal height compared to the contralateral side
- A prominent lesser trochanter compared to the contralateral side, due to external rotation of the femur
- Frog leg radiograph can be used to classify the severity of SCFE as either mild, moderate, or severe [5]
Classification
- SCFE can be classified by three ways
- Severity of the slip based on measurement of displacement
- Patient's ability to walk
- Pre-slip, Acute SCFE, Chronic SCFE, Acute-On-Chronic SCFE
Severity of Slip
- Frog leg radiograph can classify the severity of the slip
Classification | Description |
---|---|
Mild | The epiphysis is displaced less than one third the width of the metaphysis |
Moderate | The epiphysis is displaced between one-third and one-half the width of the metaphysis |
Severe | The epiphysis is displaced greater than one-half the width of the metaphysis[2] |
Ambulatory Status
Classification | Description |
---|---|
Stable SCFE |
|
Unstable SCFE |
|
History and Physical Exam Findings
Classification | Description |
---|---|
Pre-slip |
|
Acute SCFE |
|
Chronic SCFE |
|
Acute-On-Chronic SCFE |
|
Management
Prognosis
- Depends on how quickly the condition is diagnosed and treated
- Delaying diagnosis and treatment could result in early-onset degenerative hip arthritis and hip reconstruction [5]
- Prognosis also depends on whether condition is stable vs unstable
- Unstable SCFE can have up to 50% chance of osteonecrosis
- 0% chance of osteonecrosis in stable SCFE
Nonoperative
- Hip Spica Cast Immobilization
- Used only in prophylaxis to prevent SCFE in contralateral hip
- Not recommended for treatment of involved hip
Operative
- Surgical fixation with a central screw
- Most accepted treatment
- Low incidence of re-slippage, osteonecrosis, and chondrolysis
- Bone graft Epiphysiodesis
- Bone graft is harvested from the iliac crest and inserted across the growth plate
- Re-slippage common
- In situ-fixation with multiple pins
- Risk of inadequate fixation and could damage vascular supply to epiphysis [2]
Rehab and Return to Play
Rehabilitation
Return to Play
Complications
See Also
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ Weiner D. Pathogenesis of slipped capital femoral epiphysis: current concepts. Journal of Pediatric orthopedics. Part B. 1996 ;5(2):67-73.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Aronsson DD, Loder RT, Breur GJ, Weinstein SL. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg. 2006;14(12):666-679
- ↑ 3.0 3.1 Loder RT, Skopelja EN. The epidemiology and demographics of slipped capital femoral epiphysis. ISRN Orthop. 2011;2011:486512.
- ↑ Witbreuk M, van Kemenade FJ, van der Sluijs JA, Jansma EP, Rotteveel J, van Royen BJ. Slipped capital femoral epiphysis and its association with endocrine, metabolic and chronic diseases: a systematic review of the literature. J Child Orthop. 2013;7(3):213-223.
- ↑ 5.0 5.1 5.2 Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):258-262
- ↑ Gholve PA, Cameron DB, Millis MB. Slipped capital femoral epiphysis update. Curr Opin Pediatr. 2009;21(1):39-45
- ↑ Aprato A, Conti A, Bertolo F, Massè A. Slipped capital femoral epiphysis: current management strategies. Orthop Res Rev. 2019;11:47-54.
Created by:
John Kiel on 30 June 2019 19:55:47
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Last edited:
5 October 2022 13:11:08
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